Psychologists can Lead Shift to Recovery-Oriented Mental Healthcare

Psychologists are uniquely positioned to drive transformational change by promoting recovery-oriented care and socially just practices, championing the rights of both patients and staff.

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Amid rising awareness of civil rights violations in mental health systems, a newly published article in the American Journal of Orthopsychiatry, led by Erika R. Carr from Yale’s Department of Psychiatry, emphasizes the crucial role psychologists could play in championing a shift to recovery-oriented care.

Carr and her colleagues present a compelling argument for transforming the current medical model of care into a recovery-oriented approach that upholds the human rights of service users. This change is particularly advocated for those diagnosed with severe mental illness, especially within the public sector.

Carr and her team call for comprehensive changes across the institutional, community, and federal levels. These changes aim to create advocacy opportunities and facilitate social justice actions that support and collaborate with individuals determined to be severely mentally ill.

“Admittedly, many of these forms of advocacy take courage, stepping out of comfort zones as psychologists, and the awareness that there will be challenges, which must be faced,” Carr and colleagues write.
“Some of these challenges psychologists face are related to navigating our systems of care astutely, to be a voice of strength and change, while being effective and not distancing other disciplines, who still have growth in this area to expand upon.”

Relationship psychology concept with man and woman heads profiles, vector illustrationMost psychiatric settings use the traditional medical model, which focuses on diagnoses, symptoms, and a medical understanding of the etiology of mental health, with the primary treatment modality being compliance with psychopharmacological treatment. Service users have long reported feeling devalued by this approach and feeling as if treatment was coercive due to an over-emphasis on taking medication that often precipitates threatening behavior by staff to promote compliance.

Additionally, the medical model has long been criticized for overlooking the social determinants of mental health, such as structural racism, poverty, stigma, housing, education, and more. This causes a myopic understanding of professionals about the real-life challenges facing patients.

As agents of social change, psychologists training places them in a unique position to challenge the medical model of care and focus on a recovery-oriented model that centers around building meaningful lives and honoring the respect and dignity of patients with a human rights-based approach to treatment.

Given the history of human rights violations in psychiatric settings, particularly state or public health settings, there has been a movement towards more person-centered, rights-based, and recovery-oriented care.

The authors argue that advocacy is a fundamental aspect of making changes that align with a recovery-oriented model of care and that psychologists working in state hospitals and other public sector settings play a crucial role in facilitating positive change for individuals, systems of care, and at the sociopolitical level.

While many psychologists lack specific training in severe mental illness and training specifically within advocacy, they still find themselves doing this work often in the field, particularly when it comes to patient readiness for discharge. To address this lack of training, the authors suggest four primary areas to help guide psychologists toward a more recovery-oriented model of care: advocating for patients, staff, and psychology as a discipline.

Advocating for Patients

Advocating for patients often starts at the individual level through group and individual therapy focused on helping patients identify contextual and systemic factors that influence their symptoms, skill building, reducing stigma, and increasing self-esteem and hope. The authors write,

Psychologists in these settings practice advocacy by empowering the people they work with to view their experiences not just as individual illnesses but as reactions to and adaptations to a difficult upbringing, experiences of trauma, a culture of discrimination, and the sociopolitical context that has little tolerance for difference or dissent.”

This approach is aligned with social justice initiatives, where psychologists refocus on the societal context rather than focusing on the medical model that adopts a narrative of chronic disease and illness management. This also provides pathways for the patient to become empowered to act in the face of oppression rather than fall victim to it.

Understanding oppression as a contextual factor that creates conditions of mental illness highlights the need for psychologists to take action to end the effects of oppression on patients’ lives, and certain American Psychological Association guidelines even refer to psychologists as “change agents.”

This can be especially crucial and challenging in the context of state psychiatric hospitals where most patients receive treatment through the criminal justice system, often having pled “not guilty by reason of insanity” (NGRI). In these restrictive settings, there is tension around hospital policies and helping patients maintain safety under fewer restrictions. Many hospital policies cite “safety first,” and the authors urge professionals to consider the need for patients to learn how to make mistakes and tolerate distress to truly promote a recovery process, suggesting “safety first, but not safety only.” The authors write,

“Advocating for the rights of patients includes advocating for the right to fail, which can increase distress for staff members who fear both for the patient and for liability. The right to fail is the idea that there is freedom in being able to make one’s own choices and make failures and mistakes, using them as an opportunity to learn from them with forward movement.”
Advocating for Staff

In the context of inpatient facilities, it is common for psychiatric technicians and aides, often known as mental health workers, to have the most direct contact with patients. Psychologists and other mental healthcare professionals often interact with patients only for a few hours during the week for individual and group therapy and perhaps treatment team meetings. The mental health workers and nursing staff often experience the most taxing demand and the most complex behavioral challenges that lead to burnout and low morale on the units.

The authors consider what has been coined “compassion fatigue” as a significant issue for psychiatric technicians and mental health workers in these settings. Compassion fatigue has been known to decrease effectiveness among mental health professionals and give rise to feelings of inequity, emotional and physical exhaustion, depersonalization, touchiness, and even vicarious trauma.

Psychologists can play a role among staff to create systemic interventions aimed at decreasing compassion fatigue, such as including mental health technicians’ input when planning treatment. This type of involvement may increase treatment implementation efforts and create an investment and ownership of the plans developed in collaboration with staff.

Psychologists advocating for staff is critical when considering the layers of structural inequality at the organizational level in state-run facilities. The authors write,

“Ironically, dynamics within these workplaces also occur related to structural racism, classism, and oppression, as many times those serving in psychiatric technician jobs are people of color, making less pay, with more lifetime traumatic experiences and racialized trauma, who have less education and though they may spend the most time with patients, they may feel the least heard and valued and actually be the least valued.”

This knowledge highlights the necessity for psychologists to advocate for increased training opportunities for mental health technicians, focusing on evidence-based practices and self-care, mindfulness, and relational strategies. Psychologists can also use their power to advocate with senior administration for more of these opportunities directly, and while psychology may not be able to ensure participation, they can provide informal training relationally and through modeling, the dissemination of information, and encouraging questions from mental health technicians.

Advocating for Psychology

Frequently, systems of care are unaware of psychologists’ areas of expertise and skill and need psychoeducation about the roles that psychology can fill. Research has shown that there is a need for psychologists to engage in more educational dialogue about their unique skill sets so that they can engage in interdisciplinary treatment as well as create further organizational and structural change. The authors write,

“In some systems, advocating for different approaches to care may be experienced as threatening to physicians, who may typically hold most of the power in the organization. To avoid such power struggles, psychologists should be clear with open communication regarding the role and expertise of the psychologist and how it differs from (and complements) the psychiatrist’s role.”

The authors state that it is psychology’s responsibility to help change and shape the narrative by which the mental field and public view them. However, to date, there remains a lack of psychologists working in state hospitals and other public mental health settings, with the majority of clinical staff being psychiatrists and master’s level social workers.

Advocating for Recovery-Oriented Care

The authors use all of the aforementioned areas of advocacy to urge psychologists to take up the cause to transform systems of care to become more patient-centered, socially justice and recovery-based. Despite the considerable traction of recovery-oriented care in public sector spaces, particularly inpatient units, there has remained a struggle for this model to become more than just a rhetorical aim or buzzword.

The fundamental principles of recovery include self-direction, empowerment, holistic, nonlinear, strengths-based, peer support, respect, responsibility, and hope. The authors write,

“Integration of such a multifaceted set of principles in a setting dominated by the medical model requires strong and ongoing advocacy on the part of psychologists, who have many tools at hand to move these principles of recovery away from existing merely in the abstract.”

In closing, the authors highlight that these changes will require bravery and involve rethinking some of the ways in which psychologists have been trained to be “value neutral.” The authors write,

“This is not a challenge that is easy as many psychologists have frameworks or identities of neutrality, have been taught from such perspectives, have been influenced systemically that neutrality should be the case and is possible, and have had little to no training on how to engage in advocacy efforts. The field needs to grow in its efforts to teach advocacy and social justice action agendas in training, practicum’s, as well as within long term career experiences so these are not just ideological concepts that sound exciting and appeasing in a classroom, but concepts which can be put in to action, in diverse forms and settings.”

 

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Carr, E. R., Davenport, K. M., Murakami-Brundage, J. L., Robertson, S., Miller, R., & Snyder, J. (2023). From the medical model to the recovery model: Psychologists engaging in advocacy and social justice action agendas in public mental health. American Journal of Orthopsychiatry93(2), 120–130. https://doi.org/10.1037/ort0000656 (Link)

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Madison Natarajan, PhD candidate
Madison is a doctoral candidate in the Counseling Psychology PhD program at the University of Massachusetts Boston. She is currently completing her pre doctoral internship at the Massachusetts Mental Health Center/Harvard Medical School working in psychosis interventions across the lifespan. Madison primarily considers herself an identity researcher, assessing the ways in which dominant cultural norms shape aspects of racial and gender identity for minoritized individuals, with a specific focus on the intersection of evangelicalism and its relationship to Christian Nationalism. Madison has a family history that has been intertwined with psychiatric care, ranging from family members who were institutionalized to those practicing psychiatry, both in the US and India. Madison greatly values prioritizing the experiences of those with lived experience in her research and clinical work, and through her writing in MIA seeks to challenge the current structure of psychiatric care in the West and disseminate honest and empowering information to the community at large.

16 COMMENTS

  1. The psychologists I encountered during my decades as a patient with a SMI diagnosis (borderline personality disorder) were in absolute lock step with the psychiatrists in terms of invalidating me, silencing me, pathologizing me, blaming me, sending police after me, threatening me and making sure I was consistently drugged.

    They didn’t care any more than the psychiatrists about my housing situation, my so-called lack of natural supports, the trauma I’d endured (including from prior encounters with the mental health system), or the financial strain I was under, which they were happy to contribute to. When I had a life threatening physical problem that was the direct result of a prescribed psych drug, they told me I had poor coping skills and otherwise stayed silent.

    Maybe they’re just trying to save face. I would never trust any psychologist to advocate for me or lead any kind of “social justice” movement.

    If they’re serious about reform, they could start by dropping the term “severe mental illness” and disavowing the DSM. I won’t hold my breath.

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    • Agree 1000%, KateL. I would never trust any psychologist to advocate for me or lead any kind of “social justice” movement either. And it doesn’t matter what they call themselves as most pray to the same god and sing from the same hymnbook: “psychiatry” and it’s sacred “DSM”.

      To me it seemed their main concern is looking out themselves while making sure their underlings (aka “health care workers”) stay happy enough to keep fluffing their professional pillows as they add “Advocate” to their resumes. And the “clients” as usual are hung out to dry.

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    • I couldn’t agree more, KateL, it was pathological lying, systemic gas lighting, psychologists, who I found to be the worst of the worst.

      “This approach is aligned with social justice initiatives, where psychologists refocus on the societal context rather than focusing on the medical model that adopts a narrative of chronic disease and illness management.”

      This is much needed. Since the psychological industry has been unjustly functioning as nothing more than a funnel into psychiatry’s BS for decades.

      https://www.wired.com/2010/12/ff-dsmv/
      https://psychrights.org/2013/130429NIMHTransformingDiagnosis.htm

      A non-medically trained industry, of “doctors,” who honestly don’t deserve respect, since they’ve been misdiagnosing people with the “invalid” psychiatric DSM disorders, for decades – without any medical training, and without knowing anything about the common adverse and withdrawal symptoms of the psychiatric drugs … are probably “just trying to save face.”

      Although, I will admit, psychologists, your psychiatric “partners” have behaved in an ignorant manner for decades, as well.

      Just an FYI, the antidepressants and ADHD drugs can create the “bipolar” symptoms.

      https://www.amazon.com/Anatomy-Epidemic-Bullets-Psychiatric-Astonishing-ebook/dp/B0036S4EGE

      And the antidepressants and antipsychotics, both anticholinergic drugs, can also create your “schizophrenia” symptoms, via anticholinergic toxidrome, and neuroleptic induced deficit syndrome.

      https://en.wikipedia.org/wiki/Toxidrome
      https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

      Maybe it is the well researched, intelligent designers and artists who deserve more respect, rather than the psychologists, who unwisely followed psychiatry … and committed egregious paternalistic – child abuse covering up and easily recognized malpractice covering up, crimes against humanity – for decades … who deserve the actual respect?

      “The authors argue that advocacy is a fundamental aspect of making changes that align with a recovery-oriented model of care,” which we most definitely need. But psychology and psychiatry’s DSM “bible” is a stigmatization “bible,” and the antithesis of a “recovery-oriented model of care.”

      So I do hope and pray the psychologists, collectively, divorce themselves from their psychiatric DSM “bible.”

      Although, I will admit, psychologists, your psychiatric “partners” have behaved in an ignorant manner for decades, as well. An example:

      https://www.cambridge.org/core/journals/psychiatric-bulletin/article/brain-shivers-from-chat-room-to-clinic/642FBBAE131EAB792E474F02A4B2CCC0

      But to declare the psychologists to be the saviors of humanity, I think is a “delusion of grandeur,” on the part of the criminal, unrepentant, psychological community.

      What if there is actually a good and just God, who stands against “the dirty little secret of the two original [paternalistic] educated professions?”

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  2. Good effort, but the best intentions in the world can’t fix a fundamentally skewed system. And “reform” won’t mean anything as long as psychiatry remains in the driver’s seat. So, kissing the ring is just part of the job — even for (most?) psychologists.

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  3. Hi Madison, there is much truth to what Katel, Birdsong, and Someone Else write about psychologists; but not all psychologists. But it is a very difficult battle for psychologists to take part in. First, if you want to tackle SMIs you have to get past the nurses – they guard the psychiatric fortress with heightened vigilance – as a psychologist you are a threat to their position in the medical hierarchy – go away and tend to the “worried well” – “its where psychologists belong in planet mental health”. Those psychologists who have found a place there have largely succumbed to the medical model – and they join the nurses on the ramparts. I’ve never had a complaint from a “consumer” but have had several from colleagues.
    Best strategy if you get a “consumer” who has a SMI is to keep quiet about it if you can and build allies in their social network. Then your practice can be informed by the likes of Seikkula (etc)’s Open Dialogue, Tuke’s empowerment model, John Perry’s Diabasis etc .
    It is also good to build an alliance with one psychiatrist – the one least wedded to the medical model. But if he or she leaves or dies you must be prepared to move on also as you are likely in a very vulnerable place.
    Its all very well for Erika Carr to advocate that psychologists should play a more active role in the politics of MH, she is probably safe at Yale’s department of psychiatry – but the majority of us are not so safe ….

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    • This was my experience as well, working “behind enemy lines.” I wasn’t even a psychologist, just a “mental health professional.” We had very little power to alter what the psychiatrists decided to say or do. It was a constant battle, but had to be conducted as a “reasonable conversation” or you were quickly branded as an “anti-meds” worker. I eventually gave up on trying to change the system from the inside. I don’t think it’s possible. I’ve become more of an “abolitionist” the longer I work with this crazed system.

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    • Me too, Birdsong.

      If the infighting and power struggles between different MH system professionals (nurses, psychiatrists and psychologists) are as that extreme (as Nick and Steve describe), how dare any member of one of these professions accuse “borderlines” (or any patient) of “splitting”.

      The patients are not causing the disagreements. The patients have no power. The patients are at the bottom of the hill, hoping they don’t get hit with what’s rolling down it.

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  4. I am for anything that works. Whether it is medication, therapy, ECT, EMDR, witch doctors, leeches, better nutrition, meditation or primal screaming. Maybe I am not understanding the foundational truths of the recovery model. But how am I as a person suffering 24×7 from mental illness supposed to guide my own recovery, develop helpful insight that I can apply in my community setting, and effectively pull myself up by my own bootstraps with a pat on the back from my friends and neighbors when I can’t even sleep more than 4 hrs a night or walk through a grocery store without having a panic attack. I am beginning to think there are simply different strata of existence and some of us suffer more than others, some of us have more psychological distress than others, some of us put more of a burden on the care system, etc., and the world goes on. Maybe this is not the burden of society but merely part of being a member of the human race. We will never have 100% of people physically or psychologically well, and life goes on. Call it what you will, a paraplegic is a paraplegic and a schizophrenic is a schizophrenic. War, pollution, microplastics, climate change, are right alongside affordable housing, sustainable fishing and farming, and free education. The good, the bad and the ugly. Always has been, always will be.

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